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U. S. NAVY 
MEDICINE 



July 1979 




Contributing Editors 

Contributing Editor-in-Chief: CDR E.L. Tay- 
lor (MC); Dental Corps: CAPT R.W. Koch 
(DC); Education: LT R.E. Bubb (MSC); Oc- 
cupational Medicine: CDR J.J. Bellanca 
(MC); Preventive Medicine: CAPT D.F. 
Hoeffler{MC) 







POLICY: U.S. Navy Medicine a an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and profession*! information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement, by the Department of the Navy or the Bu- 
reau of Medicine and Surgery- Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members, Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor. U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202) 254- 
4253, 254-4316. 254-4214; Antovon 294-4253, 294-4316, 294- 
4214, Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-3S). 



U. S. NAVY 
MEDICINE 



Vol. 70, No. 7 
July 1979 



NAVMED P-5U5S 



1 From the Surgeon General 

2 Department Rounds 

"Eagle of the Sea" or "Angel of Mercy" 

4 Interview 

The Blue Angels' Physician 

6 Scholars' Scuttlebutt 

101 Days in the Life of a Destroyer Doctor or Medicine on the High 

Seas 

LTJ.R. Fraser. MC, USNR 

9 Independent Duty— Update 

Managing the Dissatisfied Patient 
CAPT J.J. Bellanca, MC, USN 

10 Education and Training 

Navy Graduate Medical Education 
CDR E.L. Taylor, MC, USN 

13 Reserve 

Medical Program . . . Reservist Develops Management Informa- 
tion 

14 Features 

"They're Killing mel" — The Diagnosis of Occupational Disease 
CAPT J.J. Bellanca, MC, USN 

17 Navy Psychiatric Technicians in the Outpatient Setting 
CDR T. G. Carlton, MC, USN 

20 Professional 

Cardiovascular Conditioning/Weight Control Program 
LT G.R. Banta, MSC, USN 

27 Notes and Announcements 

29 BUMED SITREP 

COVER: LCDR Charles Thomason, Blue Angels flight surgeon, and 
Mr, Dale Specht, representative of the McDonnell-Douglas Aircraft 
Corporation, watch the squadron execute a low-level pass. 



FROM THE SURGEON GENERAL 



Productivity 



Are you aware that our inpatient 
and outpatient work loads have de- 
creased over the past few years? 
Are you aware that in many in- 
stances our staffing levels are as 
high or higher than they were a few 
years ago? Yet, at the same time we 
all recognize and acknowledge our 
personnel shortages. What is the 
key to this paradox? 

The answers are complex and 
routed in several factors. First, the 
patterns of treatment and the 
emphasis of health care delivery 
have changed dramatically. Ad- 
vances in our knowledge and tech- 
niques have enabled us to shorten 
hospital stays and to manage many 
problems in an ambulatory status 
which previously required in-house 
care. A corollary has been the de- 
velopment of special care units so 
that newer, sophisticated, and far 
more effective modes of therapy 
may be dispensed. 

These developments have gen- 
erated great changes in both types 
and numbers of trained people 
needed in our system. 

Secondly, more and more of our 
attention and energies have been 
shifted from treatment toward pre- 
vention. 



These two major evolutions do in 
fact partially answer the question I 
have raised. But we must also rec- 
ognize that our individual produc- 
tivity has gone down. We are not 
unique; it is being recognized and 
talked about in other areas of our 
society today. It is a problem we 
should each address at all levels. 

We must ask ourselves, "Can't I 
personally do just a little more?" 
Isn't it possible to use time better, 
to see one more patient or accom- 
plish one more test or study? Do we 
utilize our appointment times to 
their fullest? Have we allowed our 
clinic and operating times to con- 
tract? Have we allowed our confer- 
ence time and administrative tasks 
to impinge on normal direct care 
hours? 

I think we would have to answer 
most of these questions in the af- 
firmative. Efforts, both individual 
and corporate, will turn this trend 
around. 




>/ 




W.P. ARENTZEN 

Vice Admiral, Medical CbTps 

United States Navy 



Volume 70, July 1979 



DEPARTMENT ROUNDS 

"Eagle of the Sea" or 
"Angel of Mercy" 



Though nicknamed "Eagle of the 
Sea" and designed as an implement 
of war, the USS Tarawa (LHA-1), an 
amphibious assault ship, can also 
function as a disaster relief center 
for victims of a natural disaster. 

Tarawa was the first of its class 
and was designed to function not 
only as a tactical integrity capable of 
getting a balanced Marine force to 
the same point at the same time but 
also to serve in a humanitarian role 
when needed. 

The 20- story, San Diego-based 
ship carries a Marine Battalion 
Landing Force, along with the sup- 
plies and equipment needed in an 
assault, and lands them by helicop- 
ter and small amphibious craft. 

Yet Tarawa's humanitarian capa- 
bilities are among the best in the 
Navy today. Whether it's a typhoon, 
earthquake, or flood, the 40,000-ton 
"Eagle of the Sea" can provide 
food, clothing, shelter, medical 
care, communications, and trans- 
portation to disaster victims. 

Tarawa follows the long-standing 
Navy tradition of rendering aid 
when needed. As the late Fleet 
Admiral Chester W. Nimitz once 
said, "The U.S. Navy's errands of 
mercy have saved more lives than 
its guns have ever destroyed." 

The heart of this 820-foot metal- 
lic sanctuary is it's modern medical 
and dental facilities, among the 
largest afloat today. 

Within Tarawa are four operating 
rooms, two X-ray rooms, a blood 
bank, laboratories, pharmacy, phys- 
ical therapy room, diet pantry, a 



300-bed ward with an intensive care 
unit, a three-chair dental clinic, and 
a dental laboratory. 

"The facilities are hard to com- 
prehend for someone who doesn't 
know much about medicine, but for 
someone who does they're almost 
unbelieveable," said LT James M. 
Stansbury (MC), Tarawa's medical 
officer. "This would be a major 
stateside hospital in a community of 
about 20,000 and we have most of 
the facilities they would have. 

"We have the capabilities to 
handle almost any medical problem 
or surgery, with the exception of 
open heart and micro surgery," he 
added. 

Tarawa's medical facilities were 
designed to handle up to 300 com- 
bat casualties or victims of a natural 





One of Tarawa 's four operating rooms 



U.S. Navy Medicine 



disaster and to provide outpatient 
care for approximately 2,000 per- 
sons. 

Though Dr. Stansbury and his 
staff of 15 hospital corpsmen 
couldn't handle the full load in 
event of an actual combat situation 
or natural disaster, they would be 
augmented by additional Navy 
medical personnel. 

"Our dental facilities give us the 
capability to do anything a dentist in 
private practice can do," said LCDR 
Bruce E. Schindles (DC). "It's got 
totally up-to-date equipment and 
it's very easy to reach in dental sur- 
geries." 

Under normal conditions the den- 
tal facilities are manned by Dr. 
Schindles and four dental techni- 
cians. 

Tarawa's first opportunity to 
demonstrate her humanitarian cap- 





]mW 


*4 


L li£ " 




i 1 JHnH 



Hospital corpsmen inventory their medical supplies. 




Dr. Schindles (left) works on a patient in one of Tarawa's up-to-date dental chairs. 



abilities occurred during her initial 
Western Pacific deployment with 
the U.S. Seventh Fleet. The ship 
aided more than 400 Vietnamese 
refugees transferred to them from 
the frigate USS Robert E. Peary 
(FF-1073) after their rescue in May. 

"It was probably one of the more 
rewarding things I have been 
involved with during the deploy- 
ment," said Dr. Stansbury. "When 
you render aid, people don't care 
what your politics are. You're help- 
ing them and they're grateful," he 
added. "That's what's so rewarding 
— it's priceless." 

The refugee's berthing area soon 
turned into a maternity ward with 
the birth of a baby girl, the first 
baby born on a Tarawa-class ship. 
The baby was delivered by HM2 
Richard E. Reed assigned to the 
embarked Marines. 

"He called me about 3 a.m., but 
by the time I got there he had done 
all the work," said Dr. Stansbury. 

Appropriately, the baby was 
named Grace Tarawa Tran. 

— Story and photos by JOl James R. Giusti 



Volume 70, July 1979 



INTERVIEW 



The Blue Angels' Physician 



Since 1946, the Blue Angels Flight 
Demonstration Squadron has ably 
represented Navy and Marine Corps 
aviation before millions of specta- 
tors around the world. 

The squadron is manned by 15 
officers and 74 enlisted personnel. 
The demonstration pilots are highly 
trained tactical jet pilots with many 
thousands of hours flying experi- 
ence. They also are masters of low 
altitude tactical maneuvers, per- 
forming rolls, loops, and close 
formation flying with equal preci- 
sion. 

They are not occasional aviators 
but fly almost every day, honing 
their skills for the 75 performances 
the Blues give each year. 

The pilots and their shiny blue 
A-4 Skyhawks may be the stars, but 
keeping them healthy and flying is 
the job ofLCDR Charles Thomason, 
who became the Blue Angels' new 
flight surgeon this past April. 

Dr. Thomason is a soft spoken 32- 
year-old Oklahoman and a graduate 
of Oklahoma State University and 
the medical school of Oklahoma 
University. Before joining the Navy 
in 1977, Dr. Thomason interned in 
Spokane, Wash., and practiced gen- 
eral medicine in Glasgow, Mon. 

U.S. Navy Medicine talked with 
him before a recent Blue Angels 
performance at Andrews Air Force 
Base, Md. 



USNM: When you think of the Blue 
Angels, you think of a highly 
trained and elite group of pilots, 
physically and psychologically in 



peak condition. As their physician, 
what kinds of medical problems do 
you encounter? 

LCDR Thomason: The most fre- 
quent things are colds, gastrointes- 
tinal disturbances — types of mala- 
dies that really have little to do with 
overall physical condition. I also 
treat those minor injuries that go 
along with athletics. 




to T/ 

LCDR Thomason 

Do you often encounter conditions 
peculiar to aviation such as burst 
eardrums or change of altitude 
problems? 

Occasionally we encounter baroti- 
tis or barosinusitis but these pilots 
have a great deal of experience and 
they know how to handle problems 
associated with a cold. Seldom do I 
run into serious problems. 

You have a C-130 support plane 
that flies with the team. What type 
of medical equipment do you have 
aboard? 



We have three first aid kits; two 
are standard medical issue and the 
third has an assortment of required 
bandages as well as convenience 
items like suntan oil, Kaopectate, 
decongestants, etc. 

How much do you rely on the 
local community for medical support 
during a performance? 

All the military fields have heli- 
copters, ambulances, and crash 
crews. Civilian show sites generally 
have crash crews and ambulances 
on a standby basis. 

Do you have any special duties to 
perform during the performances? 

Yes. I have to monitor and 
evaluate the pilots' performance. I 
listen to the cockpit communications 
and look for particular changes or 
increases in stress. One of the 
reasons for having a flight surgeon 
with the group is to monitor psy- 
chological profiles. Hopefully he 
can benefit the whole operation 
from an accident prevention stand- 
point. 

Speaking of stress, the risks in- 
volved in high speed aviation are 
evident. The style of flying these 
men are accustomed to is obviously 
more exacting and dangerous. Are 
they affected by this stress? 

They fly the same routine almost 
daily and develop tolerance to it. 
You're right about it being more 
hazardous. However, the important 
thing is not that their job creates 
stress as much as that stress may 
affect their job. 



U.S. Navy Medicine 




Six Blue Angel Sky hawks roll down the runway for takeoff. 



It seems as though you have to be 
as much a psychologist as a physi- 
cian to deal with this problem. Were 
you adequately trained to deal with 
stress? 

The NAMI (Naval Aerospace 
Medical Institute) flight surgeon 
program touches the problem in 
some depth, particularly as it af- 
fects aviators. 

What is the NAMI flight surgeon 
program? 

It's basically a wide-based review 
of different specialties, mostly ENT, 
psychiatry, cardiology, aviation 
physiology, and several other areas 
relating to aviation. 

Are you an aviator yourself? 

A civilian aviator, yes. I used to 
do a fair amount of flying but I 
won't have much time now. 



What do you and the team do in 
your off hours, what few you have? 

I'm starting to catch up on the 
medical journals and I'm doing a lot 
of other reading. 

Often there are many other com- 
mitments at show sites. On our 
recent tour of the west coast, every 
other night meant a dinner or re- 
ception. The demonstration pilots 
and some of the enlisted personnel 
also talk and lecture at schools and 
civic clubs in the mornings prior to 
flying. Often these ancillary duties 
are more stressful on a day-to-day 
basis than the actual flying. 

What kind of physical condition- 
ing do the pilots undergo to main- 
tain their condition? 

Each one of the pilots runs about 
five or six miles a day. 

Would you call it jogging? 

No, I wouldn't call it jogging at 



all. They run a pretty decent pace. I 
certainly can't keep up with them. 
Some play tennis and all are avid 
sports enthusiasts, 

I understand that as the Blues' 
flight surgeon, you also have some 
responsibility to the Blue Angel 
community or family in Pensacola. 
Granted that being a Blue Angel 
pilot is a hazardous occupation, it 
also must put a great deal of strain 
on the families. There are long 
separations, and the realization that 
someday the head of the household 
might not come home. Have you 
found this to be the case? 

Honestly, I haven't been in Pen- 
sacola long enough yet to determine 
that, having only joined the Blues a 
short time ago. But I do realize it 
would be beneficial to have more 
contact with the community and I 
expect to in the future. 



Volume 70, July 1979 



SCHOLAR'S SCUTTLEBUTT 



101 Days in the Life of a Destroyer Doctor 
or Medicine on the High Seas 



LT James R. Fraser, MC, USNR 



"What was it really like?" Since returning from a 
Mediterranean deployment, where I served as Squad- 
ron Medical Officer for Destroyer Squadron Twenty, 
I've been asked this question dozens of times by my 
cohorts, anxious interns, and Navy Health Professions 
Scholarship Program medical students. The curiosity 
and concern are easily understood; last year at this 
time, I was asking the same question. 

While serving as a first-year Family Practice Resi- 
dent at NRMC Charleston, I was informed that I would 
be required to serve in an operational billet before con- 
tinuing with my residency. To say the least, I was not 
initially overjoyed with the news, as I had planned on 
completing residency before beginning practice as a 
Navy Family Practitioner. However, as the internship 
year wore on, and I began to grow weary of every third 
night on duty, I honestly began to look forward to my 
new assignment. 

After completion of internship, I jumped from the 
world of institutionalized medicine to the world of medi- 
cine at sea. Following a three-day orientation course for 
prospective ship's doctors, I flew from Norfolk to 
Augusta Bay, Sicily, where I joined my new command 
and its flagship, the USS Dewey (DDG 45). 

My new command, Destroyer Squadron Twenty, con- 
sisted of two DDG's (Guided Missile Destroyers), a DD 
(destroyer), and three fast frigates, or more aptly put 
for those of you who know as much as I did at the time, 
six L.G.B.'s (large grey boats). 



This article is an edited version of a talk presented at the Surgeon 
General's Graduate Medical Education Workshop on 17 Jan 1979 to 
the Workshop attendees and the BUMED staff. 

LT Fraser has extended with COMDESRON 20, FPO New York 
09501. 



My duties as Squadron Medical Officer (SMO) were 
somewhat atypical in the sense that I had medical re- 
sponsibility for not just one ship, but a squadron con- 
sisting of six ships. However, as I spent the majority of 
my time aboard the flagship, I think my experiences 
were similar to those of any other sea-going medical of- 
ficer. In general, my responsibility as SMO was to ad- 
vise the Commodore concerning the health, hygiene, 
sanitation, and safety affecting the squadron, and to 
care for the sick and injured. My feelings when I ar- 
rived were probably typical of any young physician with 
such a new set of responsibilities; 1 wondered if I would 
be able to handle them. In retrospect, I think any well- 
trained and motivated medical officer can indeed fulfill 
those responsibilities. 

To give you some idea about the facilities I had to 
work with, I'll describe the USS Dewey's medical de- 
partment. It was amazingly small, about 8' x 8'. It con- 
tained a fold-down examining table, small desk, small 
refrigerator, surgical sink, and an autoclave. On 
shelves above and below were stocked the most com- 
monly used pharmaceuticals, intravenous solutions, 
and parenteral medications. The room would be filled 
to capacity with but one patient and two other persons 
working therein. It was often uncomfortably warm and 
was always noisy. Any patients waiting to be seen had 
to stand outside in a narrow passageway. The other 
squadron ships had similar medical departments. 

As you might expect, the laboratory capability was 
extremely limited. We could spin down hematocrits, 
had kits for doing mono spots and RPR's, and had a 
microscope with which to look at urine specimens, gram 
stains, etc. No radiology equipment was available. We 
did have a portable defibrillator which, fortunately, we 
never had to use. 



U.S. Navy Medicine 



The types of illnesses and injuries we saw ran the 
gamut, but as you would expect, most were the simpler 
maladies well within the competence of any doctor. In 
decreasing frequency, they were: 

• U.R.I, and viral syndrome complaints 

• Acute and chronic orthopedic complaints, includ- 
ing low back and other muscular strain 

• Skin disorders, including scabies, tenia, cellulitis, 
abcesses, impetigo, folliculitis, acne, and non-specific 
rashes 

• Gastrointestinal complaints 

• Headaches 

• Soft tissue trauma including minor burns and 
lacerations requiring suture 

• Behavioral problems including psychological coun- 
seling and/or evaluation for substance abuse 

• Genito-urinary and other complaints secondary to 
sexually transmitted diseases 

• Physical exams 

Three patients were med-evaced during my three 
and a half months at sea, one for repeated suicidal 
gestures, one for marked depression, and one for acute 
hepatitis. 

One of my important duties was the preventive 
aspects of shipboard medicine. This initially caused 
me some apprehension. I didn't remember courses in 
med school on food and water quality, temperature and 
ventilation, barbershop and scullery operations, or 
cockroach control. These are indeed important sub- 
jects, and a medical officer can learn about them from 
orientation, his predecessor, and from the manuals. 
However, my own best source of knowledge was the 
excellent Chief Corpsman aboard the Dewey. 

The actual performance of these preventive and sani- 
tation duties is assumed by well-trained and knowl- 
edgeable corpsmen. The medical officer supervises 
quality control and interprets and communicates his 
findings to the appropriate command in order that ap- 
propriate preventive or corrective action can be taken, 

In terms of actual man-hours spent with patients, the 
most time was spent on psychological assessment and 
counseling. The stresses of life and work aboard ship, 
made worse by extended deployment, separations, and 
immature personalities created many situations that 
the medical department had to deal with. Many sick- 
call complaints were secondary to these underlying 
psychological stresses. The medical department pro- 
vided the necessary catharsis, counseling, and en- 
couragement, and served as a significant morale 
booster for the crew. 

Another one of my jobs was to educate the corpsmen, 
stretcher bearers, and the ship's crew. All ships have 



requirements for training in topics such as first aid, 
nuclear, biological, and chemical warfare decontamina- 
tion, preventive health measures, substance abuse, and 
sexually transmitted diseases. A medical officer's 
knowledge and interest provides real impetus for the 
instruction of these topics. 

Even though there is always the possibility of 
medical crisis aboard any deployed ship, the medical 
services I provided during my three and a half months 
at sea most often involved the straightforward and 
commonplace problems well within the competence of 
any well-trained physician. As a result of the work 
environment and living spaces, traumatic injury was 
common, few of the injuries were life-threatening or 
serious, and I found my minor surgical skills adequate. 




LT Fraser 

Other skills I found most useful were general outpatient 
medicine, some psychological and counseling experi- 
ence, a basic understanding of preventive health 
measures, and potentially most in demand, a knowl- 
edge of initial management and supportive measures 
for the critically ill or injured. 

After spending my first 10 days at sea playing war 
games, we steamed into Palma de Mallorca, a beautiful 
Spanish island in the Mediterranean known for its 
beaches, castles, and its attraction to Northern Euro- 
pean tourists. I can't think of anything I didn't like 
about Palma. I did, however, work hard there. Several 
ships that had not had access to a medical officer for 
months had quite a backlog of consults, physicals, psy- 
chiatric, drug abuse, and alcoholism evals. All were in 



Volume 70, July 1979 



need of medical officer messing and berthing inspec- 
tions. There also seemed to be an excessive number of 
liberty casualties as well as an outbreak of rather 
virulant gastroenteritis. At times, I felt like a busy 
intern all over again. There was time, however, for an 
excellent U.S.O. show with Miss America and six other 
talented state representatives. 

After Palma, we returned to sea for nine more days of 
war games and I welcomed the needed rest and the 
time to read and relax. As I mentioned, I was busy at 
Palma, but being at sea was usually another matter. In 
general, my days were low-key, and I'd encourage any 
sea-going medical officer to take plenty of reading 
material, both medical and otherwise. 

A typical day would be to rise between 0700 and 
0800. Breakfast in the wardroom was ready much 
earlier, but as I almost always read late, I slept late to 
make up for it. During breakfast, I would answer my 
message traffic. This is how a good deal of medical 
consultation is handled with corpsmen on the other 
ships or with EPMU-7 in Naples. Consultations are also 
conducted via ship-to-ship phone when ships are close 
enough or by coded teletype when they are out of range 
and there is some urgency. 

I would then drop by sickbay for consultation. I'd 
often talk with the corpsman at that time about various 
medical topics. 

Lunch was at 1130. In the afternoon, after completing 
any physical exams or scheduled appointments, I'd 
usually go up to the 05 deck to catch some sun, read, or 
play chess or scrabble. Dinner was an event not to be 
missed aboard the Dewey, where the meals as with 
most squadron ships, were generally good to excellent. 

At 2000 movies were shown in the wardroom. During 
and after movie hours, I also got to know the Commo- 
dore, Captain, and Chaplain well. 

Getting to know the officers and men aboard ship was 
a real pleasure. It's easy in our profession to become 
almost exclusively involved in medically oriented social 
circles. It was enlightening to get to know others and 
talk about their interests and their work. I found that if 
you show interest in what your shipmates are doing, 
they will bend over backward to explain it to you. In this 
way, I learned a smattering about navigation, opera- 
tions, weapons, and engineering. I had heard some- 
where that line officers were antagonistic toward the 
Medical Corps. I found that not to be the case. On the 
contrary, I felt my presence and contributions were 
very much appreciated. 

On those occasions when my presence was required 
aboard the other ships, I was treated royally. Getting 
there, however, especially during rough seas, is 
another experience. Transfer is usually by helicopter 



rather than by small boat. This does not mean they land 
to pick you up and land to let you off. Instead, they 
snatch you from the ship's fantail by hoist with a horse 
collar stuck beneath your arms. While hovering 30 to 40 
feet above you, they sometimes start you spinning as 
they're hosting you up. Getting lowered from a pitching 
and rolling helicopter onto a pitching and rolling deck is 
also highly recommended for relieving boredom. 

Our next liberty port was Barcelona, Spain. The fol- 
lowing 18 days were some of the most memorable of my 
life. My wife had made arrangements to fly over and 
meet me. After making arrangements for potential 
emergency coverage, we began an odyssey through 
Spain and France, including eight days in Paris. Suffice 
it to say that it was a wonderful opportunity and we had 
the time of our lives. 

After 18 days of upkeep, the ship left Barcelona and 
returned to sea for still more war games. By this time, I 
had become a hard-core stargazer and had learned to 
identify the major constellations. On a clear night with 
calm seas, one can truly say there is something about 
being at sea that's soothing to the psyche. 

Our last liberty port was Monaco on the French 
Riviera. Monaco was superb and we were treated as 
guests with free admission arranged at the casinos, 
museums, and golf and tennis clubs. We were able to 
return the favor when over 50 of the Dewey's crew 
donated blood to ease a local shortage. 

After six days in Monaco, we again went to sea for 
our final round of war games and this time were ac- 
companied by 15 to 20-foot seas for about three days. 
This was a time I'd just as soon forget, but I'm sure I 
won't. It also provided for some of my best sea stories. 
Trying to suture a laceration or start an I.V. while 
trying to hold onto something stationary to keep from 
being bashed into the bulkhead is an interesting chal- 
lenge. We all survived, however, though some of the 
superstructure of the ship did not. 

Finally, we departed Rota, Spain, and steamed a 
leisurely 12 days across the Atlantic to Charleston. 

In retrospect, I look back to all the new experiences I 
had while deployed, and realize that I probably would 
never have had them hadn't I been required to go oper- 
ational. I have no regrets. There is no doubt that the 
experience has helped me become a better Navy doctor. 

Despite the fact that many Navy doctors are repelled 
by the idea of serving aboard ship, I would encourage 
them to personally experience what makes "Navy" for 
the Navy physician. Deployment is not only a challenge 
in an alien environment with limited space and re- 
sources. It is also an opportunity for personal and pro- 
fessional enrichment and a once-in-a-lifetime chance to 
see "what it's really like." 



8 



U.S. Navy Medicine 



INDEPENDENT DUTY - UPDATE 



Managing the Dissatisfied Patient 



CAPT Joseph J. Bellanca, MC, USN 



The best way out of difficulty is 
usually through it. Lost medical 
records, prolonged waiting peri- 
ods, medication errors, appoint- 
ment delays, and unsatisfactory 
treatment results are common 
sources of dissatisfaction which 
make patients angry and damage 
important therapeutic relationships. 
Distraught patients can seriously 
disrupt the smooth operation of a 
medical care facility, and in some 
cases, lead to malpractice situa- 
tions. All of us know things can go 
wrong and, as long as you are the 
one on the firing line, you are the 
one who has to set them right. Don't 
make excuses, prove you under- 
stand, and never belittle. These are 
the three basic rules. 

The most important rule is the 
one on excuses. If ever there is a 
time to think positively, it's when 
the patient is hopping mad. The 
good approach in this situation is to 
keep in mind that this is an oppor- 



From the Department of the Navy, Bureau 
of Medicine and Surgery (MED 3142), Wash- 
ington, D.C. 20372. 



tunity to demonstrate "patient 
care!" 

The best bet is to see the patient 
as soon as possible and listen to his 
or her story. Maybe you feel the 
complaint is unjustified, but never 
say so, and don't give the impres- 
sion that you think he is making a 
mountain out of a molehill. To him 
it's a very important matter. 

Listen to the complete story with- 
out interrupting. After he blows his 
top, he should be in a better frame 
of mind. Also, by letting him talk 
until he has finished his complaint, 
you get the facts. You can't find a 
satisfactory solution without them. 

When the unhappy patient has 
told you why he is dissatisfied, 
prove that you understand his com- 
plaint by repeating it as you under- 
stand it. This gives the patient the 
opportunity to correct any false con- 
clusions which you may have reach- 
ed. The other important advantage 
of you repeating the story is that it 
gives the patient an opportunity to 
see the complaint in a different 
light. Often, he ends up agreeing 
that the matter is not as important 
as it appeared to be when he first 



became aware that something was 
wrong. 

Probably your first reaction to a 
patient complaint is "What's he all 
excited for? A lot worse things 
happen everyday," Maybe so, but 
to this patient, at this particular 
moment, this incident is very im- 
portant. That's why you must never 
belittle his perception. Sometimes it 
is even helpful to inflate the impor- 
tance of the complaint, almost to a 
point of exaggeration. Ask for more 
details by explaining that the more 
you know about the situation, the 
better prepared you'll be to prevent 
it from happening again. If you 
don't overdo it, which can make him 
think you are ridiculing him, you 
may soon hear the patient say, "Oh, 
it's not so bad as your making it out 
to be." Then he is helping you find 
an equitable solution. 

In summary, the three important 
principles in handling complaints 
well are: don't make excuses, prove 
you understand, and never belittle. 
Satisfactory complaint handling 
proves you really care. Always do 
what is right; it will gratify some 
people and astonish the rest. 



Volume 70, July 1979 



EDUCATION & TRAINING 



Navy Graduate Medical Education 

CDR E.L. Taylor, MC, USN 



The 11th Surgeon General's Specialties Advisory Com- 
mittees' (SAC XI) Conference will convene in the 
Washington, D.C. area 9-14 Sept 1979. The purpose of 
this conference is primarily to review all Graduate 
Medical Education (GME) applications and nominate 
selectees for Navy GME to the Surgeon General. The 
SAC XI Conference will perform many other functions 
during this convening, i.e. discuss issues related to 
GME, review teaching staff projections, exchange 
ideas and philosophies, and make formal recommenda- 
tions to the Surgeon General and his selected panel of 
advisors. 

Graduate Medical Education Availability 

The Navy offers 33 GME training programs in 8 
teaching medical centers. Four are multidisciplinary 
and four are Family Practice Training Hospitals: 

Multidisciplinary 
NNMC Bethesda, Md. 
NRMC Oakland, Calif. 
NRMC Portsmouth, Va. 
NRMC San Diego, Calif. 

Family Practice 
NRMC Charleston, S.C. 
NRMC Camp Pendleton, Calif. 
NRMC Jacksonville, Fla. 
NARMC Pensacola, Fla. 

Individual Navy GME programs and the number of 
positions available in each program for 1980-1981 are 
listed in Table 1. 

Applications should be forwarded to: 

Commanding Officer 

Naval Health Sciences Education & Training Command 

(ATTN: Code 4) 

National Naval Medical Center 

Bethesda, Md. 20014 

Deadline for receipt of all applications - 15 Aug 1979 



Interviews 

Persona] interviews with program director are 
strongly encouraged. Expenses incurred for interviews 
are the responsibility of the applicant. 

Selection Process 

Each specialty committee reviews appropriate appli- 
cations and makes recommendations for selection to the 
Surgeon General who has sole and final approval au- 
thority. As a guide to past selection rates, see Table 2. 

Selection Priorities 

The following priorities will continue to be used to 
select qualified applicants for all GME programs: 

First Priority 

Presently serving in an operational/utilization tour. 

Second Priority 

Incumbent GME1 (interns) with significant previous 

active duty. 

Third Priority 

Incumbent GME1 (interns) with no previous active 
duty. (Active duty, in the Uniformed Services Univer- 
sity of the Health Sciences, is not in itself, considered 
as a priority). 

Fourth Priority 
Inactive reserve 

Fifth Priority 
Civilian applicants 

These priorities assure the qualified applicant, who is 
serving in an operational/utilization tour, usually after 
his GME-1 year, an excellent chance for returning to 
the specialty training of his choice. This SAC XI com- 
mittee will not only recommend selection of 1980 GME 
trainees, but will be strongly encouraged to recommend 
selection of trainees for 1981. Outyear selection num- 
bers will be guided by priorities set within the Bureau 
of Medicine and Surgery. This will, in certain cases, 



10 



U.S. Navy Medicine 



TABLE 1 : Residencies /Fellowships in Naval Activities Indicating Positions 
at Each Year Level by Activity 







Years of training 
offered 


Number of positions 
each year 


«3 

■o 
in 

<u 
■C 
+J 
o 
a? 


c 
o 

4-> 
01 

-o 

c 

O) 

o 


o 
+-> 
in 

<v 

T. 

rO 


■r— 

> 

o 

o 

<o 


-a 

(0 

to 
o 


ro 

o 
o 

(O 

c 
a> 
a. 


+J 
o 

E 
l/> 

+-> 

s_ 
o 
a. 


o 

at 

Q 

c 
ro 


ai 
o 


Aeros 


pace Medicine * 


3 


& 












6 








Anest 


fiesiology * 


2 


20 


6 








4 




4 


6 




Dermatology * 


3 


8 


3 














5 




Family Practice * 


2 


38 




9 


9 


12 




8 








Hand Surgery 


1 


1 
















1 




Internal Medicine 
and Subspecialties * 


3 


30 


6 








4 




8 


12 




Cardiology 


2 


6 


2 














4 




Endocrinology & 
Metabolism 


2 


3 


2 








1 










Gastroenterology 


2 


3 


1 














2 




Hematology/Oncoiogy 


3 


4 


2 














2 




Infectious Disease 


2 


4 


2 














2 




Nephrology 


2 


1 
















1 




Pulmonary Disease 


2 


4 


1 












1 


2 




Neurology 


3 


3 


3 


















Neurosurgery * 


4 


1 


1 


















Nuclear Medicine 


2 


3 


2 








1 










Obstetrics & Gynecology 


3 


18 


3 








3 




6 


6 




Maternal Fetal 


2 


1 


1 


















Occupational Medicine * 


3 


1 


















1 


Ophthalmology * 


3 


9 


4 








2 






3 




Orthopedic Surgery * 


4 


12 


2 








3 




3 


4 




Otolaryngology * 


4 


10 


2 








3 




2 


3 




Pathology * 


4 


10 


3 








2 




2 


3 




Hematopathology 


1 


1 


1 


















Pediatrics * 


3 


18 


3 








3 




6 


6 




Plastic Surgery 


2 


1 














1 






Preventive Medicine 

(General) * 


3 


1 


















1 


Psychiatry * 


3 


11 


4 








3 




4 






Radiology * 


3 


17 


6 








3 






8 




Surgery * 


4 


13 


3 








2 




4 


4 




Peripheral Vascular Surgery 


1 


1 
















1 




Thoracic & CV Surgery 


2 


2 


1 














1 




Urology * 


4 


6 


1 








1 




2 


2 





'Indicates numbers of years training beyond GME year one. 



Volume 70, July 1979 



11 



TABLE 2: GME (Residency and Fellowship) 
Statistics SAC X, Sept 1978 



Status 



Percent 
Applicants Selected Selected 



Resident 
(For Fellowship) 


29 


23 


79% 


Incumbent Intern 


183 


71 


39% 


Operat ional / Uti I izat ion * 


210 


135 


63% 


Inactive Reserve 


31 


3 


10% 


Other Military 


3 


1 


33% 


Civilian 


63 


9 


14% 


Total 


519 


242 


46% 


*The term "Operational/Utilization' 
mary care medical officers applying 
from a nontraining status. 


' encompasses all pri- 
or reapplying for GME 



preclude the necessity for reapplication on the part of 
the incumbent intern required to serve in an opera- 
tional tour prior to GME-2 and will guarantee place- 
ment two years in advance. 

Notification Date 

Following adjournment of SAC XI, and an internal 
Bureau review, the Surgeon General will conduct a final 
review and approve committee selection recommen- 
dations according to the needs of the Navy. Advance 
notice of selection, alternate or nonselect status may 
not be divulged until the Surgeon General has officially 
approved the slate of nominees. 

As soon as possible after approval of the Surgeon 
General, (approximately 15 Oct 1979) applicants will be 
notified of the SAC XI results via letter. 

Responsibility of Applicant After Notification 

The official notification will include information as to 
selection, alternate, or nonselection status, and a ser- 
vice training obligation agreement. Selectees are re- 
quired to notify the Naval Health Sciences Education 
and Training Command of acceptance or declination 
within 10 days of receipt of the notification. Failure to 
respond will result in the position being offered to 
another qualified candidate. 

Outservice Training 

Each year a limited number of individuals are se- 
lected for full-time outservice training in civilian in- 



stitutions. These specialties are determined by the 
Bureau Advisory Board and are placed in an order of 
priority according to the critical needs of the Navy 
Medical Department. For the SAC XI Conference, the 
following priorities have been established for outser- 
vice training: 

Priority Specialty/ 'Subspecialty Listing for Full-Time 
Outservice Training 

(1) Specialty and subspecialties of Orthopedic Surgery 

(2) Aerospace Medicine 

(3) Critical Care Medicine 

(4) Emergency Medicine 

(5) Surgical subspecialties 

a. Plastic Surgery 

b. Neurosurgery 

c. Pediatric Surgery 

(6) Subspecialties of Interna! Medicine 

a. Rheumatology 

b. Nephrology 

c. Tropical Medicine 

d. Infectious Disease 

e. Allergy/Immunology 

(7) Occupational Medicine 

(8) Preventive Medicine 

(9) Stress Physiology 

(10) Underwater Physiology 

(11) Physical Medicine 

(12) Rehabilitation Medicine 

(13) Ophthalmology subspecialties 

(14) Pediatric subspecialties 

(15) Obstetrics/Gynecology subspecialties 

(16) Psychiatric subspecialties 

NOTE: No. 5 and No. 6 receive equal consideration 

Applicants for full-time outservice training are re- 
sponsible for seeking and being accepted by the civilian 
institutions. The application process for full-time out- 
service training is identical to the inservice procedure 
and applicants are considered at the annual SAC Con- 
ference. No commitment from either the Navy or the 
applicant can be made until the SAC committee recom- 
mendations have been received and have been re- 
viewed for final approval by the Surgeon General. 



Application Process (Inservice and Outservice) 

BUMED Instruction 1520. 10G of 12 May 1976, pro- 
vides necessary guidance to those medical officers ap- 
plying for graduate medical education. 

Specific information regarding training programs 
may be obtained by contacting the appropriate depart- 



12 



U.S. Navy Medicine 



ment chairmen at the regional medical centers. Ad- 
dresses of the teaching hospitals are listed below: 

Commanding Officer 
National Naval Medical Center 
Bethesda, Md. 20014 

Commanding Officer 

Naval Regional Medical Center 

Oakland, Calif. 94627 

Commanding Officer 

Naval Regional Medical Center 

Portsmouth, Va. 23708 

Commanding Officer 

Naval Regional Medical Center 

San Diego, Calif. 92134 

Commanding Officer 

Naval Regional Medical Center 

Charleston, S.C. 29408 

Commanding Officer 

Naval Regional Medical Center 

Camp Pendleton, Calif. 92055 

Commanding Officer 

Naval Regional Medical Center 

Jacksonville, Fla. 32214 

Commanding Officer 

Naval Aerospace and Regional Medical Center 

Pensacola, Fla. 32512 

For general information regarding any questions you 
may have, HSETC is always available to assist you in 
any way possible. Best wishes to each and everyone of 
you in pursuing your Graduate Medical Education 
endeavors. 

CDR E.L. Taylor, MC, USN 
Director, Medical Corps Programs 
Naval Health Sciences Education & 

Training Command (Code 4) 
National Naval Medical Center 
Bethesda, Md. 20014 
Phone: 295-0648/9 

RADM A.C. Wilson, MC, USN 

Commanding Officer 

Naval Health Sciences Education & Training Command 

National Naval Medical Center 

Bethesda, Md. 20014 



RESERVE 



MEDICAL PROGRAM 

The Chief of Naval Operations has approved the 
transfer of Program 9 — Marine Corps Forces Selected 
Reserve billets currently authorized for the First, 
Second, and Third Marine Amphibious Forces to Pro- 
gram 32. These billets are being utilized to reconstruct 
Naval Regional Medical Center Units similar to those 
which existed prior to implementation of "Project 
Readiness." There will be approximately 101 units 
nationwide ranging in size from 3 officers/20 enlisted to 
6 officer s/27 enlisted, whose mobilization sites will be 
at selected Naval Regional Medical Centers. This 
action, which is expected to be implemented by 1 Oct 
1979, will increase female corpsmen opportunities for 
Reserve participation and will restore one of the most 
popular and successful programs that we have had in 
the Naval Reserve. As a result of the billet transfer, 
future Marine Corps mobilization requirements will be 
met by using active duty manpower resources. Existing 
Fourth Marine Division/ Air Wing units will be re- 
tained. However, a few of these units will be relocated 
in order to achieve an equitable distribution throughout 
each Naval Reserve Readiness Command. 



RESERVIST DEVELOPS MANAGE- 
MENT INFORMATION 

During the month of May, the Medical Service Corps 
Division benefited from the active duty training service 
of LCDR Susan Haberkorn, MSC, USNR-R. With train- 
ing and previous active duty experience as a physical 
therapist, LCDR Haberkorn holds a Master's degree in 
Public Health and is currently working toward a doctor- 
ate at the University of Michigan. She represents out- 
standing professional talent among our Naval Reserves. 
Previous active duty training for this officer has in- 
cluded such vital assignments as CINCLANTFLT staff. 
LCDR Haberkorn is currently drilling with A-R5 
VULCAN Detachment 613. Consequently, she is well- 
versed on matters of fleet support. During this particu- 
lar two-week period, LCDR Haberkorn developed the 
framework of a management information system for the 
Medical Service Corps Naval Reserve component, 
working closely in so doing with CAFT William Narva, 
MC, USN and LCDR Al Donohue, MSC, USN of the 
BUMED Naval Reserve Special Assistant's office. 



Volume 70, July 1979 



13 



a 



They're killing me!" 

The Diagnosis of Occupational Disease 



CAPT Joseph J. Bellanca, MC, USN 



In 1803, Lord Nelson stated, "The 
great thing in all military service is 
health, and you will agree with me 
that it is easier for an officer to keep 
men healthy than for the physician 
to cure them." The Medical Depart- 
ment exists to keep our Navy and 
Marine active forces healthy. Each 
and every health professional can 
contribute to this important effort 
by identifying occupational health 
problems caused by hazardous work 
environments and initiating appro- 
priate corrective actions. 

Bernardo Ramazzini, in the 
1700's, advised physicians about 
carefully questioning patients about 
occupation. He recognized that 
characteristic illnesses developed in 
certain trades. Through visits to the 
workplace, he was able to suggest 
precautions to prevent these ill- 
nesses. His observations about the 
connection between illness and oc- 
cupation are still valid today. 

Disease often results from the un- 
healthy encounter of an individual 
with the physical, chemical, and 
social environment. Since adults 
spend 30 to 50 percent of their time 
in a work environment, familiarity 
with that environment is essential 
for diagnosis and proper treatment. 

Occupational diseases are specific 
diseases brought on by certain dose 
exposure to work hazards. For ex- 



From the Department of the Navy, Bureau 
of Medicine and Surgery (MED 3142), Wash- 
ington, D.C. 20372. 




Some jobs could involve exposure to more than one hazard. Grinding old paint may 
cause exposure to lead dust and excessive noise. 



14 



U.S. Navy Medicine 



ample, silicosis is a specific indus- 
trial-related lung disease with de- 
finite clinical characteristics caused 
by the inhalation of minute airborne 
sand particles. It results from a 
significant dose of inhaled dust par- 
ticles within a respirable size range. 
Silicosis is caused neither by granu- 
lar sand nor silicone (a plastic), nor 
does it develop in someone exposed 
to sandblasting for only five min- 
utes. This may seem fairly evident, 
yet physicians sometimes unthink- 
ingly accept a worker's claim that 
"that stuff I breathe at work is kill- 
ing me!" These claims are fre- 
quently based on subjective distor- 
tions of toxicology. Workers often 
believe foul smelling chemicals are 
the most dangerous. In reality, foul 
odors may be harmless (sour milk), 
odorless exposures may be fatal 
(carbon monoxide), and foul smells 
may be fatal (hydrogen sulfide). 

The diagnosis of occupational 
disease is made in the same pains- 
taking manner as nonoccupational 
disease. The physician must care- 
fully consider the patient's medical 
history and then perform physical 
examination, and laboratory and 
radiological evaluations to confirm 
initial clincial impressions. To de- 
termine whether an illness is caused 
or aggravated by work, considera- 
tion should be given to other impor- 
tant factors. 

The occupational history is im- 
portant for establishing past ex- 
posures to potentially hazardous 
substances and the degree of such 
exposure. Toxic exposures can oc- 
cur on any job. It is insufficient to 
ask a person's job title and then as- 
sume their job is not hazardous. A 
clerk-typist may regularly use sol- 
vents containing trichloroethylene 
or benzene to clean the typewriter, 
or a dentist may grind potentially 
dangerous beryllium-containing 
metal on a daily basis. You may un- 
derstand what a carpenter does, but 
it is more valuable to know that he is 




Portable air sampling devices can be 
used to measure a variety of workplace 
air contaminants for comparison with 
established safe levels. 



frequently exposed to loud noise, 
and that he cuts asbestos cement 
board with a power saw without 
dust control or respiratory protec- 
tion. Don't assume the use of pro- 
tective devices — ask specific ques- 
tions. Workers are not likely to vol- 
unteer information when they are 
negligent in following required 
safety procedures. 

When evaluating an illness of oc- 
cupational origin, one must go 
beyond those exposures occurring 
in the present job. Past exposures to 
potential health hazards may be 
equally significant. Interstitial fi- 
brosis identified on a chest X-ray 
may have had its origin in the dusty 
environment of a previous job. The 
X-ray changes of asbestos exposure 
sometimes takes 20 years from 
initial exposure until the radio- 
graphic manifestations of the dis- 
ease become evident. 

You must identify the specific 
substances handled, the intensity, 
route, and duration of exposures, 



the protective clothing used by the 
worker, and the engineering con- 
trols employed. Most potentially 
toxic materials to which a worker is 
exposed in his occupation are in- 
haled, but the skin and the gastro- 
intestinal tract may also be routes of 
entry. Workers exposed to lead dust 
may ingest it when they eat in the 
workplace without first washing 
their hands properly. Many solvents 
can be absorbed systemically when 
spilled on the skin or clothes. 

Individual workers may give very 
different descriptions of the same 
exposure, either exaggerating or 
minimizing, depending upon per- 
sonal beliefs and motives. Useful 
data can often be obtained from the 
supervisor or the safety manager 
and other individuals familiar with 
the workplace and the patient's job. 
The presence or absence of similar 
effects or signs or symptoms of dis- 
ease in fellow workers sharing es- 
sentially the same environment is 
important and useful. (It is also 
helpful to know if someone at home 
has a similar illness). 

If monitoring devices or air sam- 
pling techniques have been used to 
evaluate the working environment, 
the analytical results should be ob- 
tained and compared to accepted 
standards such as the ACGIH 
Threshold Limit Values. Textbooks, 
journals, and public health authori- 
ties are promptly available for con- 
sultation by the physician unfamil- 
iar with these procedures and 
standards. 

In acute poisoning, specific tests 
for the quantitative determination 
of the suspected material or one of 
its metabolites in the blood, urine, 
or breath should be done promptly 
if they are available. Hematological, 
biochemical, or other tests likely to 
indicate absorption or particular 
effects of a toxic agent should be 
carried out. However, the mere 
presence of a particular compound 
in an elevated concentration in a 



Volume 70, July 1979 



15 




Work involving hazardous exposures should not cause illness when proper precau- 
tions are employed. 



certain organ or tissue of the body 
does not necessarily indicate that an 
intoxication has taken place. A labo- 
ratory chit indicating that "blood 
lead levels above the normal value 
of 30 ug/100 ml are,toxic" is mis- 
leading. The normal blood lead 
value reflects lead that is ingested 
or inhaled as part of our normal 
environment. Elevated blood lead 
suggests increased lead exposure, 
and when above 80 ug/100 ml in 
adults, warns of the possible onset 
of lead neuropathy. The significance 



of elevated concentration of a toxic 
substance in body fluids must be 
carefully evaluated in terms of accu- 
mulated medical knowledge. Repe- 
tition of a specific test after discon- 
tinuation of exposure may provide 
additional important information. 

Certain individuals in the work 
population have increased suscepti- 
bility to some chemical exposures. 
Medications, allergies, smoking, 
and alcoholism are all factors which 
can interact with otherwise safe 
levels of environmental contami- 



nants to produce disease. The 
toxicity of ethylene dibromide is in- 
creased in workers taking Anta- 
buse. Teflon dust is not toxic except 
when it contaminates cigarettes to 
cause "polymer fume fever." Al- 
lergy-prone individuals may be 
particularly at risk in work environ- 
ments where certain allergenic 
chemicals such as isocyanates are 
used. The aging worker may also be 
at special risk. 

Occupational disease may be 
mimicked by nonoccupational dis- 
ease. A common example is the oc- 
currence of abnormal liver function 
studies in workers exposed to po- 
tentially hepatotoxic chemicals. Al- 
though experienced physicians rec- 
ognize that heavy alcohol ingestion 
is clearly the most frequent cause of 
liver dysfunction in the working 
population, occupational exposures 
are often overlooked. 

Detrimental exposures may also 
occur away from work. The moon- 
lighting worker or one who has a 
hobby involving potentially hazard- 
ous materials may be endangered. 
A welder protected by excellent 
exhaust ventilation at his daily 
worksite may ignore all precau- 
tions while welding at another job. 
The home itself may not insure 
a safe environment. The most fre- 
quent cause of acute arsenic poison- 
ing in this country is a homicidal 
spouse. 

Diagnosis should be based on 
mature consideration of all the 
findings by history and clinical ex- 
amination. This is particularly so in 
the case of occupational disease be- 
cause other workers may also be 
involved. If you suspect an unsafe 
workplace, you should contact the 
appropriate public health officials. 
They will conduct environmental 
and epidemiological studies and 
recommend the hygienic and engi- 
neering practices for remedying 
hazardous situations. Prevention is 
the best cure. 



16 



U.S. Navy Medicine 



Navy Psychiatric Technicians in 
the Outpatient Setting 



CDR Thomas G, Carlton, MC, USN 



The recent drastic reductions in Navy psychiatric man- 
power have tended to focus attention on more efficient 
means of delivering mental health services. One long 
overlooked resource is the Psychiatric Technician (NEC 
8485). 

The Army, the Air Force, and many civilian mental 
health centers have long recognized a broad role for 
mental health technicians. (1-6) The Army, for ex- 
ample, has schools to train technicians for outpatient 
work (including psychological and social work skills) 
and for the administrative aspects of military psychia- 
try. Our fellow services have assigned mental health 
technicians to independent duty with indirect psychiat- 
ric supervision, apparently with considerable success. 
These technicians have been able to provide mental 
health services where they would otherwise be unavail- 
able. (1, 2, 5) 

Macht(7) has pointed out the need for a viable 
career ladder and opportunities for paraprofessionals. 
There is currently no such career ladder for Navy men- 
tal health technicians. Shortly after promotion to HM2 
(E-5), the technician is usually afforded no option but to 
leave psychiatry and/or the Navy. A common "re- 
ward" for senior technicians has been to remove them 
from the clinical setting. Anyone closely associated 
with Navy psychiatry is painfully aware of the low re- 
enlistment rate for these technicians. 

Navy psychiatric technicians, unlike those of the 
other services, are trained only for inpatient work. 
Indeed, they are the only technicians listed together 
with general duty ward corpsmen (NEC 0000) in a 
recent report on the Navy Occupational Task Analysis 
Program. (8) Navy psychiatric technicians are expected 
to be assigned to nursing units and their billets are 
generally assigned on the basis of inpatient statistics 
alone, with no consideration of outpatient loads. When 
psychiatric wards of a facility have been closed, the 



CDR Carlton is assistant chief of Psychiatry for Outpatient Psy- 
chiatric Services, NRMC Portsmouth, Va. 23708. 



technicians have often been reassigned to nonpsychiat- 
ric duties either on medical wards or in such areas as 
transportation, special services, and laundry. This has 
been true even at facilities with heavy psychiatric out- 
patient loads. 

A number of recent factors have combined to begin to 
change the role of the technician in Navy psychiatry. 
Among these factors have been: 

• The drop in the number of Navy psychiatrists, 
which appears to be with us for some time. 

• The increased pressure to keep patients out of the 
hospitals. 

• The increased expectation that Navy psychiatry 
should provide a broader range of services, along the 
lines of mental health centers. 

• The recently increased importance of physician ex- 
tenders in all Fields of medical care. 

• The apparent poor morale among Navy psychiatric 
technicians who have become aware that their's is a 
deadend job. 

• The recent re-recognition among many Navy psy- 
chiatrists that Navy psychiatry is largely community, 
consultative, preventive, and industrial psychiatry. 

In response to these and other factors, a number of 
Navy psychiatry departments have begun to use tech- 
nicians more and more in the outpatient setting. These 
changes have generally been very well received by the 
technicians and psychiatrists involved. The response 
from commands, the patients, and referral sources has 
been favorable, as it has been in the past for the Army. 

Often these changes have initially been brought 
about somewhat sub rosa in spite of the wealth of favor- 
able experience, as though they were somehow illicit. 
Even with the hesitant starts, the results of these 
changes have been encouraging. The author has had 
personal experience with utilization of psychiatric tech- 
nicians at two quite different commands which can 
serve as examples. 



Volume 70, July 1979 



17 



Example 1 

In 1974 through most of 1975, the Naval Regional 
Medical Center, Camp Lejeune, N.C., had a fairly 
classical psychiatric outpatient clinic with two psychia- 
trists and a psychologist seeing new outpatients at the 
center hospital. Patients were scheduled for a standard 
psychiatric hour and there was a six- to eight-week wait 
for active duty appointments. There were also two out- 
lying clinics operating somewhat similarly. The average 
inpatient load was around 45 patients on two wards. 
Essentially all these patients were local admissions, 
with almost no medevacs. 

In 1975 and early 1976, the psychiatry department 
went through a period of ' 'experimentation ' ' to attempt 
to shorten the waiting time for appointments and to 
reduce admissions. 

The psychiatric clinic obtained two psychiatric tech- 
nicians for outpatient work. These were experienced 
senior technicians who screened all first-visit patients 
through questionnaire and interview. The technician 
then arranged for the patient to spend an appropriate 
amount of time with the psychiatrist or psychologist. A 
block appointment system was used, with groups of 
patients arriving and beginning their paperwork at the 
same time. Technicians on the inpatient wards were 
also trained to do basic intake interviews on emergency 
room patients. This provided an onboard watchstander 
with mental health training who could see patients in 
crisis at night and on weekends and work out followup 
arrangements with the on-call psychiatrist. 

With these changes, emergency referrals were much 
less disruptive; the average waiting list time was re- 
duced from more than six weeks to within two working 
days for first-visit evaluations. The number of "no- 
shows" dropped markedly. Most surprisingly, the ad- 
mission rate dropped dramatically. Over a period of 
several months, the average census dropped to less 
than one-third of what it had been. This seemed to 
represent primarily a decrease in those admissions 
precipitated by impulsive behaviors in response to frus- 
tration. It appeared that one major factor in the changes 
observed lay in an increased ability to provide suppor- 
tive contact earlier, either in the emergency room or in 
the clinic, and that without the technicians these 
changes would not have been seen. This is admittedly 
anecdotal data and the cause and effect relationship is 
conjecture, but it is compatible with the Army experi- 
ence. {/) 

Example 2 

The Naval Regional Medical Center, Portsmouth, 
Va., has also faced a problem of providing timely care, 



but it has faced the additional problem of providing 
local care throughout a farflung and heavily populated 
region. It is an accepted axiom of military psychiatry 
that most acute problems can be handled better, with 
more likely restoration to duty, if they are treated 
rapidly and near "the front" (in this case the ship, 
squadron, or shore command). It is very difficult to 
provide adequate service to people who must travel 25 
miles or more and take at least half a day off from work 
for each appointment. 

Using psychiatric technicians in a manner similar to 
that described above for Camp Lejeune, Portsmouth 
has established four psychiatric clinics in strategic 
locations throughout the region, with each clinic being 
responsible for specific catchment populations. These 
clinics have relied very heavily upon psychiatric tech- 
nicians to enable them to provide timely, local services. 
Indeed, three clinics are staffed only by a technician at 
some time during the week. 

The technicians serve primarily as intake inter- 
viewers, but they have also been used quite success- 
fully in a number of other areas, including: 

• Emergency evaluations and crisis intervention. 

• Administration of questionnaires and psychologi- 
cal tests. 

• Supportive counselling. 

• Referral to other appropriate sources such as 
counselling and assistance centers, chaplains, social 
service agencies, Navy Relief, etc, 

• Command and agency consultations including 
visits to ships in port. 

• Training non psychiatric corpsmen in basic mental 
health skills, particularly interviewing. 

• Participation in contingency-oriented crisis inter- 
vention teams. 

Obviously good supervision is a vital part of the pro- 
gram, with each technician being supervised by a 
mental health professional (psychiatrist, psychologist, 
or psychiatric social worker) who is responsible for that 
technician's work. 

There have been very few problems or complaints. 
Considerable praise for the technicians has been heard 
from outside the psychiatry department, and line com- 
mands have been very happy to be receiving prompt, 
local service. The only impediment encountered to date 
has been that of making enough experienced techni- 
cians available for outpatient work. This difficulty 
stems at least partly from current assignment policies, 
inpatient needs, and nursing service controls over tech- 
nicians. 

Portsmouth is now in the process of establishing a 



18 



U.S. Navy Medicine 



local program to train experienced psychiatric techni- 
cians in outpatient work. 

Discussion 

In view of the increasing demands on Navy psychia- 
try and the decreased numbers of Navy psychiatrists, 
technicians have become more important both in the 
day-to-day operation of clinics and in contingency 
planning. Increased utilization of psychiatric techni- 
cians in the outpatient setting has even facilitated some 
expansion of services in the face of dwindling psychiat- 
ric staff. This use of psychiatric technicians may prove 
particularly helpful in small clinics where a single psy- 
chiatrist or psychologists must provide all the mental 
health support for a Navy or Marine Corps community. 

The potential effect of these and similar programs on 
retention rates among psychiatric technicians is also 
worthy of consideration. Such programs could form the 
foundation for a viable enlisted career ladder within the 
mental health field. The opportunity for advancement 
and more independent work within the field might en- 
courage more psychiatric technicians to remain on 
active duty beyond their initial obligations. The existing 
liaison with the Army training programs could be ex- 
panded to provide the advance training needed for such 
a career ladder to work. 



In summary, psychiatric technicians are a long ne- 
glected and highly valuable resource that can be 
utilized to extend the reach and expand the services of 
Navy psychiatry even in the face of present constraints. 

References 

1. Glass AJ: Mental Health Programs in the Armed Forces, in 
American Handbook of Psychiatry, 2nd ed. Edited by Ariefi S. New 
York, Basic Books, 1974, Vol II, pp 800-809. 

2. Glass AJ, Artiss K, Gibbs JJ, et al: The Current Status of 
Army Psychiatry. Am J Psychiatry 117:673-683, 1961. 

3. Bey DR, Smith WE: Mental Health Technicians in Vietnam. 
BullMeminger Clin 34:363-371, 1970. 

4. Gartner A, Reissman F: The Performance of Paraprofessionals 
in Mental Health Fields, in American Handbook of Psychiatry, 2nd 
ed. Edited by Ariefi S. New York, Basic Books, 1974. Vol II. pp 826- 
836. 

5. Nolan K.J, Cooke ET: The Training and Utilization of the 
Mental Health Paraprofessional Within the Military: The Social 
Work/Psychology Specialist. Am J Psychiatry 127:114-119, 1970. 

6. Rodeman CR, Seidenfeld MA, Rockmore MJ: The Techni- 
cians, in Neuropsychiatry in World War II. Edited by Anderson RS. 
Washington, Office of the Surgeon General, Department of the 
Army, 1966, pp 701-717. 

7. Macht LB: Community Psychiatry, in The Harvard Guide to 
Modern Psychiatry. Edited by Nicholi AM. Cambridge, Harvard 
University Press, 1978, p 646. 

8. Burkhart FA: NOTAP Collects HM Data. US Nov Med 69(6): 
11, June 1978. 



Protecting Your Prescriptions 



Recently, physicians — and, par- 
ticularly, those new in private 
practice — are being approached 
by persons exhibiting varying 
extremes of drug-seeking be- 
havior. Identifying these patients 
can become a problem; however, 
there are several clues which can 
alert you to the possibility that a 
patient may be a drug misuser/ 
abuser: 

• when an unfamiliar patient 
tells you that a controlled product 
he wants from you was previous- 
ly prescribed for him by another 
physician (either in private prac- 
tice or in a hospital) who is cur- 
rently unavailable 

* when an unfamiliar patient 
states that he is the patient of 
another physician for whom you 
may occasionally cover and 



wishes a prescription for a con- 
trolled product renewed 

When either of these situa- 
tions occurs, it is a good idea to 
ask the patient for the name of 
the physician or hospital and at- 
tempt to verify the story. If the 
patient tends to avoid answering 
your questions, it generally indi- 
cates a problem. Often with this 
type of patient, your prescription 
blank is the prime target. The 
following are some suggested 
guidelines to follow to insure its 
safety and proper use. 

1. Store all unused prescrip- 
tion pads in a safe place where 
they cannot be easily stolen. 

2. Minimize the number of 
pads in use at one time. 

3. Have prescription blanks 
numbered consecutively when 



printed so that you can tell if 
some sheets are missing. 

4. Never sign prescription 
blanks in advance. 

5. Write prescriptions in ink 
or indelible pencil to prevent 
changes. 

6- Write out the actual amount 
of medication prescribed in addi- 
tion to using an Arabic or Roman 
numeral — this discourages alter- 
ations. 

7. Do not use your prescrip- 
tion blanks for writing notes or 
memos which can be erased and 
the blanks used again. 

8. Do not leave prescription 
pads in unattended examining 
rooms, office areas or in your bag 
or car where they can be easily 
picked up. 

— Reprinted with permission of Roche 
Laboratories 



Volume 70, July 1979 



19 



Cardiovascular Conditioning/ 
Weight Control Program 



LT Guy R. Banta, MSC, USN 



This article describes a cardiovascular conditioning/ 
weight control program currently in use at Naval Air 
Station Meridian, Mississippi. It is hoped that it will 
influence the development of similar programs or that 
the methods described will be utilized by any facility, 
physician, clinical counselor, physiologist, dietition, 
etc. involved with cardiovascular conditioning and 
weight control programs. 

The development of coronary heart disease (C.H.D.) 
is well known throughout the world. In the United 
States alone the annual death tool due to C.H.D. has 
been reported to reach near 600,000. (/) Of the patients 
seen at the Cardiovascular Conditioning/Weight Con- 
trol Clinic, Meridian during the last 18 months, 41.2 
percent related a family history of C.H.D., 19.4 percent 
related a personal history of some form of underlying 
C.H.D., and 19.8 percent had abnormal blood pres- 
sures. The factors associated with C.H.D. are well 
known — hypertension, hypercholesterolemia, arterio- 
sclerosis, smoking, excessive emotional stress, ele- 
vated uric acid, inactivity, and obesity. 

Obesity is not a new problem, but in the past few 
years the Navy has begun to express substantial 
interest in the weight status of Navy personnel in rela- 
tion to performance of duty and personal appearances. 
(2,3,4,5,6) At Meridian, the number of naval personnel 
seen for weight problems only scratches the surface of 
those in the Navy and Marine Corps in need of health 
and administrative guidance (Table I). Of the 352 
patients examined, the average weight needed to be 
lost equalled 33.5 lbs/individual. The method by which 
the needed weight loss was determined will be ex- 
plained later. 

If an individual is over the maximum allowable 
weight level in reference to his height, should he be? If 
not, what is the optimal weight between the minimum 
and maximum weight levels for best health? Even 
though the individual is under the maximum allowable 
weight, should that weight be even lower when the 



LT Banta is a naval aerospace physiologist assigned to NARMC 
Branch Clinic. Naval Air Station, Meridian, Miss., as an aeromedical 
safety officer with additional duty to Training Air Wing One. 



TABLE I: Subjects Seen at the Cardiovascular 
Conditioning/Weight Control Clinic 



Total seen (past 18 months) 

Active Duty (Officer and Enlisted) 

Dependents 

Retired 

Males 

Females 



352 
301 
39 
12 
235 
117 



weight is considered in relation to body structure and 
masculature when evaluating performance capability 
and military appearance? Once these questions are 
answered, a weight control program that will enable an 
individual to lose the required weight in a sensible 
manner has to be developed. 

Types of Evaluations 

The Cardiovascular Conditioning/Weight Control 
Program handles several types of requests: 

• Voluntary request for weight evaluation by mem- 
bers who feel they need to lose or gain weight. 

• Requests by command and/or department super- 
visors of military personnel to verify compliance with 
current Navy/Marine Corps weight standards. 

• Referrals from medical department personnel for 
weight evaluation, specific diets, coronary rehabilita- 
tion programs, counseling, and exercise programs. 

• Voluntary requests by individuals for physical 
fitness status evaluations. 



TABLE II: Abnormal Blood Chemistries 



A. Cholesterol 

B. Triglycerides 

C. Glucose 

D. T4 



21.7% 

27.6% 

2.5% 

1.69% 



20 



U.S. Navy Medicine 




Stress ECG can be conducted with a treadmill or a Master's 
Two Step profile. 



Laboratory Analysis 

Once an individual has been given an appointment at 
the Cardiovascular Conditioning/Weight Control Clin- 
ic, he is instructed to fast 12-14 hours prior to the 
evaluation. This is to insure the accuracy of a blood 
analysis that will be conducted the day of his appoint- 
ment. Epidemiologic studies reported in the literature 
continually provide evidence of the possible direct pro- 
portion of C.H.D. risk with elevated serum cholesterol 
and serum triglycerides. (7,8,9) In the interest of de- 
termining indications of possible underlying disorders 
that may cause or aggrevate hyper! ipidemia and/ or 
exogenous obesity, it is vital to do a complete fasting 
SMAC and thyroid (T4) and evaluate all blood chem- 
istries. A summary of the abnormal lab results on our 
subjects has revealed the following (Table II). 



Electrocardiogram 

A 12-lead resting ECG is conducted on all personnel 
over 30 years of age as a standard procedure. For any 
individual under 30 years of age with a significant per- 
sonal history of ECG abnormality, C.H.D., or elevated 
BP, a resting and/or closely monitored stress ECG, can 
be conducted if a cardiologist and a crash cart are avail- 
able. A stress ECG conducted with a treadmill or a 
Master's Two Step profile (Figure 1) on a normal indi- 
vidual is also a good index of physical fitness level. It 
allows the recording of the individual's submaximum 
heart rate during stress. This fitness level and submaxi- 
mum heart rate determination can help determine a 
proper cardiovascular exercise program by using the 
submaximum heart rate as a monitor. (This is described 
in the exercise section of this paper.) 

Anthropometric Measurement 

Unfortunately, the Navy has fallen into the insurance 
company mold of using mean height/weight charts for 
determining allowable weight for naval personnel. The 
instruction promulgating the Navy's latest height/ 
weight chart indicates that appropriate medical facili- 
ties will determine whether an individual belongs 
within the minimum-maximum range or whether he can 
exceed the maximum allowable weight. In order to use 
this chart effectively, determine what the subject's 
ideal weight should be for good health, and to fulfill the 
Navy's maximum allowable weight, complete and ac- 
curate body measurements must be taken. 

The best method of body composition determination 
is by the human body volumeter on displacement of 
water. (10) However, even without this equipment, 
anthropometric and skin fold measurements have re- 
sulted in noteworthy "high multiple condition coeffi- 
cients and low standard errors of estimate." (11) The 
process involves the use of appropriate calipers (Fig- 
ures 2, 3). The resulting measurements are then used 
in a series of multiple regression equations. The results 
yield an ideal target weight at a recommended relative 
fat percentage (Tables III and W). (11, 12, 13) 

Exercise 

During the interview session each subject is provided 
a short educational program on the coronary system 
and basic physiology. This enables him to understand 
his own body and why the program must be followed as 
designed. After discussing the basic benefits of 
exercise i.e., reduced blood pressure, increased stroke 
volume, lowering of serum triglycerides, and weight 
loss, the subject is told about exercise at the submaxi- 
mum heart rate. (14) 



Volume 70, July 1979 



21 



TABLE III: Multiple Regression Equations 

a. Wright E. Wilmore, 1974 (Simple field test) (15) 

Lean body weight (kg) = 40.99 + 1.035(weight (kg)) - 0.6734 (abdominal 
circumferences (cm)). (S.E.E. = 3.49) 

(NOT RECOMMENDED FOR FEMALES) 

b. Wilmore & Behnke, 1968 (13) 

LBW - the square of the results of the sum of two torso measurements 
plus two extremity measurements divided by the sum of their conversion factors 
times the individual's height: (2TM + 2E *M/2TM D ) 2 x height 

I 2- 



(dm) = LBW. 
Measurements 



(diameters (cm)) 



1) Bi acromial (T) 

2) Bideltoid (T) 

3) Chest (T) 

4) Bi-iliac (T) 

5) Bitrochanteric (T) 

6) Knee (E) * 

7) Ankle (E) * 

8) Elbow (E)* 

9) Wrist (e)* 




Conversion Factors (D) 

21.3 
24.4 
15.5 
14.7 
17.3 

9.7 

7.2 

7.1 

5.9 



* Sum of right and left sides 

% body fat = present weight (kg) - LBW '(kg) /present weight (kg) 

c. Wilmore & Behnke, 1969 (14) 

% body fat = 5.783 + .153 (triceps skinfold + scapula skinfold + abdominal 
skinfold + suprailiac skinfold) 



scapula skinfold 
tricep skinfold 




suprailiac 



skinfold 




d. Ideal relative fat % range = 12.5% to 20.0% 
Recommended target weight can be calculated by dividing the actual lean body 
weight (LBW) by that fraction which represents the ideal lean body weight. 
1.000 - .125 (if 12.5% relative fat is desired) = 0.875 or target weight = 
LBW/0.875. y 



22 



U.S. Navy Medicine 



TABLE IV: Example Calculation 



Individual #1 



Height : 
Weight: 

Skinfolds 



17.02 dm 
93.98 kg 



Suprailiac: 
Abdomen: 
Scapula: 
Triceps : 



25. 2 mm 
40. 2 mm 
38. 6 mm 
21. 2 mm 



W s B: 5.783 + .153(21.2 + 38.6 + 40.2 + 25.2) = 24.9% body fat 



Anthropometry 

Biacromial: 40.0 cm 

Chest: 33.2 cm 

Bicristal: 33.7 cm 

Ankle: 7. 3 cm 

Wrist: 5.5 cm 



Bi deltoid: 

Bi trochanteric : 

Knee : 

Elbow: 



60.0 cm 
34.6 cm 

11.1 cm 
8.8 cm 



W S B: 40.0 + 33.7 + 2(7.3) + 2(5.5)/49.1 = (2.02) x 17.02 = 
69.61 kg LBW. 93.98 - 69.61/93.98 = 25.9% body fat 
12.5% relative fat desired = 69.61/. 875 = 79.56 kg. Ideal, weight = 175 lbs 



NOTE: Skinfold measurements should be used as a verification of accuracy 
when compared to the anthropometric measurements. 



The subject is then encouraged to follow one of the 
full body movement type exercise programs — walking, 
jogging, running, swimming, cycling, basketball, etc. 
This exercise regimen provides the coronary system 
sufficient stress at or near 65-80 percent of maximum 
heart rate for 15-20 minutes four days a week. The 
subject is taught to monitor his carotid pulse in order to 
insure that the submaximum heart is being maintained 
during exercise. (A common way to determine maxi- 
mum heart rate is to subtract the individual's age from 
220 BPM. For calculation of submaximum heart rate, 
use the equation: 220 BPM - age x .65 or 220 BPM - age 
x .80). Allowing the individual both to perform the exer- 
cise of his choice and monitor himself is a positive bio- 
feedback mechanism. Endurance and strength in- 
creases. Metabolic, cardiovascular, and respiratory 
functions improve, and weight loss is achieved. Table V 
lists the percentage breakdown of preferred exercise 
programs by our subjects. 



TABLE V: 


Exercise Program Selection 


Event 




Percentage 


Jogging /Running 


47.7% 


Walking 




15.6% 


Cycling 




9.6% 


Racquet ball 




3.1 % 


Rope Jumping 




2.3% 


Swimming 




1.1 % 


Basketball 




.8% 



Volume 70, July 1979 



23 





TABLE VI: Cardiovascular Conditioning /Weight Control Check List 




Aoe: 

Ht: 
Wt: 
Frame: 


yrs 
ins 
Ins 

slender 




B/P: 






lbs 
obese 


RPR- 

Maximum allowable weinht: 

medium heavy 


Skinfolds 

Chest: 
Thigh: 
Ahdomen: 


mm 
mm 
mm 




Biceps: , . 
Trif^ps* 




mm 
, mm 




Circumferences 

Neck: 

Shoulder 
Chest: 


cm 
cm 
cm 




Abdomen: 
Hips- 




, cm 
cm 




Diameters 

Biacromial: 

Chest: 

Bicristal: 

Lean body weight:. 

Fat wmight- 
Relative fat: 


cm 

cm 
cm 

kg 
kg 
% 


Bideltoid 

Bitrochanteric 

Knee 


cm 
cm 
cm 


Ankle 
Elbow 
Wrist 


cm 
cm 
cm 






Ideal {Target) Body weight: 


lbs 




kfl 






Lab 

Triqlyceride: _. 
Cholesterol: _ . . 


mg% 
mg% 




T3/T4: 

Fasting Glucose: 






Last Physical: 

ECG: 

Family History: 


Date 












Exercise: „ 
at heart rate of 


day/wk 
BPM 


min 'riav 






Diet: 


Calories 












Vegetables: 




BREAKFAST 


LUNCH 


DINNER 




Breads: 


Meats: 


Milk: 


Fruits: 


Fats: . 


WEIGH IN: 

1st week „ 


lbs date „ 




11th week 
12th week 
13th week 
14th week 
15th week 

16th week 
17th week 
18th week 
19th week 
20th week 




lbs date _ 




2nd week , 


lbs date _ 






lbs date 




3rd week _ . 


lbs date 






lbs date 




4th week 


lbs date _ 






lbs date 




5th week 


lbs date 






lbs date _ 




6th week 


lbs date 






lbs date 




7th week 


lbs date 






lbs date 




8th week _ 


lbs date _ 






lbs date 




9th week 


lbs date 






lbs date 




10th week _ 


lbs date 






lbs date 





24 



U.S. Navy Medicine 




Calipers are used for anthropometric and skin fold measurements. 



Diet 

There are probably 10,000 or so diet plans on the 
market and about as many people promoting them. The 
one that outshines the others and is most highly recom- 
mended by the medical community for weight reduc- 
tion, weight gain, and maintenance of weight, is the 
balanced diet with the reinforcement of a moderate 
exercise program. (15) 

To lose weight, calories burned must exceed caloric 
intake. This is what is achieved in a combined diet and 
exercise program. Patients are encouraged to achieve a 
weight reduction at a rate no greater than approxi- 
mately 1-1.5 kg per week average (2 to 3 lbs). This 
prevents sacrificing muscle-mass (strength and en- 
durance), helps retain the body's metabolism to adjust 
to normal state, and helps maintain the individual's 
motivation. (16) A negative caloric balance can be 
achieved by reduction of the balance input by 1000-1500 
calories/day but never to a level less than a total of 1500 
calories input for adult males or 1200 calories for adult 



females. (17) A number of ingenious methods exist 
to determine what the individual's present daily caloric 
input is at his/her present weight. (18) One of the 
simplest, is to multiply the individual's present weight 
by (xl5) and reduce accordingly 1000-1500 calories. (17) 
Table VI, in addition to listing the subject's total 
work-up, will reveal a recommended balanced diet 
plan. By placing the maximum servings allowed in the 
blank spaces corresponding to the food groups and 
meals allows the individual to design his own meal 
plan. The equating of the servings to be placed on the 
diet sheet and a list of the available food is also pro- 
vided. (19) However, if the laboratory analysis and 
other medical evaluation reveal dangerous levels of 
cholesterol, triglycerides, thyroid imbalance, other 
abnormal blood chemistries, underlying C.H.D., hyper- 
tension, etc., specific diets and/or medications might 
be necessary until a level of acceptance can be 
achieved. Only then can the individual be allowed to 
continue on a "balanced" diet/no medication program. 



Volume 70, July 1979 



25 



However, medication usually will not inhibit participa- 
tion in the basic diet/exercise program. In fact, partici- 
pation is essential. 

Conclusion 

The program has a success rate of 76 percent based 
on the number of participants who have reached or are 
continuing toward their goals. This high success rate 
can be attributed both to the scientific approach of diet/ 
exercise programming and the positive motivation 
developed in each individual that comes to the clinic. 
This positive motivation and continued effort by the pa- 
tient is not as difficult to achieve as many feel. What it 
takes is what we all desire, individual attention. With 
the massive numbers of people in need of medical 
guidance and with the shortage of medical staff, it is 
easy to pull out the height/weight chart, give out a pre- 
printed diet plan and tell people to lose weight. Our 
plan may take more time, but we are achieving success 
with a professional approach to a Navy- wide problem. 
The subject usually feels obligated to give us as much 
effort as we give him. His education about health main- 
tenance for himself and his family is substantially 
enhanced. 

The individualized approach of this program is 
further enhanced by weekly monitoring of weight loss, 
bimonthly interval laboratory analysis, and ECG's. 
Encouragement of supervisors or commands to ac- 
knowledge the individual's participation and success on 
evaluations also seems to help. 

Similar programs in the Navy should be developed. 
The need is there. In order for U.S. Navy and Marine 
Corps personnel to remain healthy and maintain them- 
selves at a level of peak performance, the commitment 
to this kind of health maintenance is essential. 

References 

1 . Cooper KH, Pollock ML, et al: Physical Fitness Levels vs 
Selected Coronary Risk Factors. A cross sectional study. JAMA 236: 



116-169, 1976. 

2. BUPERSMAN 3420440 of Jan 1978. Weight Control Policies 
and Procedures of Administrativeiy Handling Obese Personnel. 
Bureau of Naval Personnel, Wash., D.C. 

3. BUPERSINST 6110. 2B of Oct 1976. Weight Control: Guide- 
lines and Responsibilities. Bureau of Naval Personnel, Wash., D.C. 

4. BUPERSNOTE 1616 of Dec 1977. Reporting of Individual 
Height and Weight Status on Enlisted Performance Evaluations. 
Bureau of Naval Personnel, Wash,, D.C. 

5. Manual of the Medical Department Weight Standards for Navy 
and Marine Corps Personnel. Physical standards, articles 15-17, 
1978. Bureau of Medicine and Surgery, Department of the Navy, 
Wash., D.C. 

6. Marine Corps Order 61 10.36 of 23 Sept 1975: Physical Fitness, 
Weight Control and Military Appearance. Headquarters, Marine 
Corps, Wash., D.C. 

7. Margolis S: Treatment of Hyperlipidemia. JAMA 239:2696- 
2698, 1978. 

8. Lees RS, Lees AM: Therapy of the Hyperlipidemia. Post Grad 
Med 60:99-107, 1976. 

9. Kannel WB, Castelli WP, Gordon T, et al: Serum Cholesterol, 
Lipoproteins, and the Risk of Coronary Heart Disease. Ann Intern 
Med 74:1-12, 1971. 

10. Allen TH: Measurement of Human Body Fat: A Quantitative 
Method for Use by Aviation Medical Officers. Aero Med Oct 1963. 

11. Wilmore JH, Behnke AR: Predictability of Lean Body Weight 
Through Anthropometric Assessment in College Men. J Appl Physiol 
25:349-355. 1968. 

12. Wilmore JH, Behnke AR: An Anthropometric Estimation of 
Body Density and Lean Body Weight in Young Men. J Appl Physiol 
27:25-31, 1969. 

13. Wright HF, Wilmore JH: Estimation of Relative Body Fat and 
Lean Body Weight in a United States Marine Corps Population. Aero 
Med 301-306, March 1974. 

14. Exercise Testing and Training Apparently Healthy Individuals: 
A Handbook for Physicians. American Heart Association, New York, 
1975. 

15. Frtbers H (ed): Weight Control: Advising Patients About Fad 
Diets, Patient Care 78-104, June 1976. 

16. Smith NJ: Gaining and Losing Weight in Athletics. JAMA 236: 
149-171, 1976. 

17. Allsen PE, Harrison JM, Vance B: Fitness for Life. An Indi- 
vidualized Approach. WC Brown Co, Dubuque, Iowa, 1975. 

18. Lamar SR: Human Energy Requirements: A Simple Tool for 
Assessment in a Weight Control Program. US Nav Med 67(6):22-25, 
June 1976. 

19. Daily Menu Guide. Eli Lilly and Co, Indianapolis, Ind., 1972. 



U.S. Navy Medicine 



NOTES & ANNOUNCEMENTS 



IN MEMORIAM 

Leonard A. Duce, Ph.D., who for 22 years gave faith- 
ful and dedicated leadership and service to the Federal 
medical services, died on 9 June 1979 in San Antonio, 
Tex., at age 70. 

Born in Princeton, Ontario, Canada on 26 May 1909, 
Dr. Duce received a Bachelor of Arts degree and his 
Theological Training at McMaster University, Hamil- 
ton, Ontario. From 1931 to 1942, he served in 
pastorates in Ontario, Massachusetts, and Connecticut. 
He began his career in education in 1943 at William 
Jewell College, Liberty, Mo., where he was Professor 
of Philosophy and Dean. In 1946, he received a Ph.D. 
from Yale University and then joined the faculty at 
Baylor University as professor and chairman of the 
Department of Philosophy. During the 11 years at 
Baylor, he became more involved in education adminis- 
tration serving as Assistant Dean, Associate Dean, and 
ultimately as Dean of the graduate school. From 1960 to 
1974, Dr. Duce held the position of Dean of the gradu- 
ate school and Professor of Philosophy and Business 
Administration at Trinity University. In 1976, after 19 
years of service as a lecturer, he became the Director of 
the Interagency Institute for Federal Health Care 
Executives. 

The Interagency Institute was initiated 27 years ago 
by the Federal medical services to provide an organized 
means of developing professional management among 
the various agencies responsible for the delivery of 
medical care under Federal Government sponsorship. 
It has continued to provide a two- week course con- 
ducted semiannually under the sponsorship of the De- 
partments of the Army, Navy, Air Force, Public Health 
Service, and the Veterans Administration. Under Dr. 
Duce's leadership, the Institute's focus on providing a 
forum for the sharing of experience among all the 
Federal health agencies increased significantly. He 
brought to the directorship the talents of a superb edu- 
cational administrator who was energetic and insightful 
in his approaches to program improvement. 



CAPT Philip Van Horn Weems, USN (Ret.), a navi- 
gation researcher, died 2 June 1979 at age 90. 

CAPT Weems was born in Montgomery, Tenn., and 
graduated from the U.S. Naval Academy in 1912. His 
duty assignments included the command of the USS 
Hopkins and instructor at the Navy's postgraduate 
school. He was the first air navigation research officer 



assigned at the Naval Hydrographic Office. CAPT 
Weems retired in 1933, but was recalled to active duty 
in 1942. During World War II he was a convoy com- 
mander, an assignment for which he was awarded the 
Bronze Star. He retired again in 1946, but in 1961 was 
recalled to active duty to conduct a pilot class in space 
navigation. He retired again in 1962. 

Following his first retirement, he founded the 
Weems System of Navigation, a navigation instrument 
and publishing company in Annapolis, Md. Many of the 
instruments and systems developed under his direction 
are still used in sea and air navigation. 

CAPT Weems' first textbook, "Air Navigation," 
won the gold medal of the Aero Club of France in 1931. 
During his long career, he wrote more than 400 articles 
and held seven patents for navigation instruments. His 
awards include the John Oliver La Gorce Medal of the 
National Geographic Society, the Thurlow Award of the 
Institute of Navigation, and the Magellanic Premium of 
the American Philosophical Society. 

CAPT Weems most noteworthy projects were the 
star altitude curves for celestial navigation and the 
development of the modern air almanac, a combination 
which made practical the long-range air navigation 
missions of World War II. 

GASTROINTESTINAL ENDOSCOPY FOR 
THE SURGEON 

The National Naval Medical Center and the Uni- 
formed Services University of the Health Sciences, 
Bethesda, Md., will sponsor a symposium on Gastroin- 
testinal Endoscopy for the Surgeon 26-28 Sept 1979. 

For further information write: CAPT L.E. Smith, 
MC, USN, Box 175, National Naval Medical Center, 
Bethesda, Md. 20014. 



ATTENTION NAVY AUTHORS 

Many articles by Navy personnel appear each 
year in a variety of professional journals and other 
publications. U.S. Navy Medicine would like to 
include a monthly list of some of these articles 
written by Navy authors from all corps. If you 
have published recently and would like to share 
your research or perceptions with your colleagues, 
please send us the title, name, and issue of the 
publication in which your article appeared. 



Volume 70, July 1979 



27 



WEST COAST NURSING SYMPOSIUM 

This is the second year of the West Coast Nursing 
Symposium, presented by the Navy Nurse Corps, under 
the sponsorship of the Health Sciences Education and 
Training Command (HSETC), Bethesda, Md. The 
symposium will be held 1-2 Oct 1979 in conjunction with 
the 86th Annual Meeting of the Association of Military 
Surgeons of the United States (AMSUS) slated for 2-6 
Oct 1979 at the Town and Country Convention Center, 
San Diego, Calif. 

The West Coast Nursing Symposium represents an 
opportunity for nurses to share knowledge, ideas, 
skills, and fellowship. It provides nurses from many- 
areas of expertise a forum in which to learn from lead- 
ers and each other, the opportunity to update knowl- 
edge, and to develop ideas concerning current trends in 
professional nursing. 

The symposium will be conducted by clinical nurses 
on relevent topics in all areas of clinical practice. Wide 
use of multimedia and simultaneous sessions highlight 
the offerings available to the participants. The sympo- 
sium aims to explore and highlight many of the con- 
temporary issues, challenges, and opportunities of 
clinical nursing. 

This symposium has been approved by the California 
Board of Registered Nursing and by HSETC for a maxi- 
mum of 10 contact hours. HSETC is accredited by the 
Northeast Regional Accrediting Committee of the 
American Nurses' Association. The actual number of 
contact hours granted will depend on the total number 
of sessions attended. In order to comply with the Board 
of Registered Nursing requirements, registrants must 
attend an entire session and will be required to com- 
plete an evaluation tool. Procedures for documenting 
attendance at sessions and for obtaining and submit- 
ting evaluation tools will be detailed in the official pro- 
gram. 

The entrance fee for the nursing symposium will be 
$40 and also entitles participation in the AMSUS con- 
vention. 



UNIVERSITY OF CALIFORNIA COURSES 

The Department of Extended Programs in Medical 
Education at the University of California School of 
Medicine will sponsor the following courses: 

Topics in Energency Medicine 17-21 Sept 1979 

The objective of this program is to instruct the par- 
ticipants in depth through didactic presentations, case 
studies, student/teacher interactions and demonstra- 
tions in the approach to problems in the emergency 



department. Upon completion of this program, regis- 
trants should be more competent in handling injuries of 
the hand and face, in diagnosing and treating acute 
cardiac disease, in interpreting radiographs, and in 
managing problems in other areas including pediatrics, 
ophthalmology, neurology, and obstetrics/gynecology. 
Pre- and post-course assessments will be available, as 
will a syllabus with references. 

The program meets the criteria for 40 credit hours in 
Category I of the Physicians' Recognition Award of the 
American Medical Association and the Certification 
Program of the California Medical Association. The 
course is also approved for 39 hours in Category I by the 
American College of Emergency Physicians, and is ac- 
ceptable for 40 elective hours by the American Acad- 
emy of Family Physicians. 

Update in Obstetrics 4-6 Oct 1979 

This symposium will provide the most current infor- 
mation in obstetrics. The program is designed for 
clinicians involved in the health care of the pregnant 
woman. This program should provide concise, practi- 
cal, and current clinical information concerning con- 
temporary issues in obstetrics. 

The course meets the criteria for 14 credit hours in 
Category I of the Physicians' Recognition Award of the 
American Medical Association and the Certification 
Program of the California Medical Association, and 14 
cognates, formal learning, of the American College of 
Obstetricians and Gynecologists. 

For more information write or call: Extended Pro- 
grams in Medical Education, University of California, 
Room569-U, Third and Parnassus Ave., San Francisco, 
Calif. 94143. Telephone (415) 666-4251. 

RECENT ARTICLES BY NAVY AUTHORS 

The Intra-axonal Transport of Evans Blue Albumin 
Within the Vagus Nerve to the Duodenum by ENS 
Kevin S. Kennedy, MC, USNR and W.M. Yau. Gastro- 
enterology 76:1168, May 1979. 

Cytologic Description of Squamous Cell Papilloma of 
the Respiratory Tract by CDR Lawrence R. Rubel, MC, 
USN and HM1 Robert E. Reynolds, CT, ASCP, USN. 
Acta Cytologica 23:227-230, 1979. 

AMERICAN COLLEGE OF 
EMERGENCY PHYSICIANS 

The next Government Services Chapter, American 
College of Emergency Physicians will be held during 
the 1-4 Oct 1979 Annual ACEP Scientific Assembly, 
Atlanta, Ga. 



U.S. Navy Medicine 



BUMED SITREP 



SHORE ESTABLISHMENT REALIGNMENT 
ACTIONS NOTED 

On 1 June 1979, Shore Establishment Realignment 
(SER) actions become effective at four medical facili- 
ties. The four facilities affected, formerly Naval Hos- 
pitals, are new Naval Regional Medical Clinics and 
have ceased or are phasing out inpatient services. The 
four facilities affected are: Naval Regional Medical 
Clinic, Annapolis, Md.; Naval Regional Medical Clinic, 
Port Hueneme, Calif.; Naval Regional Medical Clinic, 
Key West, Fla.; and Naval Regional Medical Clinic, 
Quantico, Va. Steps are underway to consolidate the 
clinic functions remaining at these facilities and turn 
vacated buildings back to the host commands where 
they are located. 

CHAMPUS UNVEILS REVIEW PROGRAM 
FOR MENTAL HEALTH CARE 

A pioneering program designed to protect both pa- 
tients and the government from paying for mental 
health care that is not appropriate for the condition 
being treated has been unveiled by CHAMPUS offi- 
cials. 

Individual cases will be examined by panels of psy- 
chiatrists or psychologists (depending on the treatment 
involved), and CHAMPUS payments will be ended for 
any care a panel determines to be inappropriate. 

CHAMPUS officials enlisted the aid of the American 
Psychiatric Association and the American Psychological 
Association in developing standards for determining 
appropriateness and in establishing review procedures. 
These two professional organizations have also identi- 
fied individuals who will serve on the panels. 

Involvement of the two organizations adds a new 
dimension to the long-standing CHAMPUS effort to 
protect beneficiaries from paying for mental health care 
that is not appropriate for their problem. This is the 
first time that national mental health professional 
organizations have been involved in establishing 
standards of appropriateness and a review program. 

The first reviews are already under way. Eventually, 
all outpatient mental health care that extends beyond a 
few visits and any institutional mental health care that 
goes beyond a few days will be reviewed. The only 
exception will be care received in a residential treat- 
ment center which must be authorized by OCHAMPUS 
before it is started. 

Volume 70, July 1979 



MEDICO-LEGAL FEEDBACK— VTDEO TAPES 
ON MEDICINE AND LAW 

The VA, in conjunction with the American College of 
Legal Medicine, has recently produced a series of six 
video cassettes entitled "Current Problems in Medicine 
and the Law." The six subtitles of this series are (1) An 
Overview; (2) Professional Duty to the Patient; (3) Pa- 
tient Injury Prevention; (4) The Medical Record; (5) 
When a Claim is Filed; and (6) Defense of a Law Suit. 
Each cassette runs 15-20 minutes. A set of the tapes 
has been provided to BUMED (001B), and it is available 
for loan to any command wishing to use it for staff 
meetings, officer indoctrination, and the like. The tapes 
can be used for individual viewing; however, greater 
benefit will be gained by group presentations followed 
by discussion of the various issues presented. A Navy 
Judge Advocate could be requested to assist in leading 
the discussion. (Commands that do not have a Staff 
Judge Advocate on board may coordinate with the local 
Naval Legal Service Office.) While the series was 
prepared for the use within the milieu of the VA, most 
of the information has application to all Federal health 
care delivery systems, and much of it is applicable to 
the non-Federal sector as well. To heighten the series' 
usefulness, the VA plans to publish study guides and 
quiz materia! to accompany each cassette. These will be 
made available upon receipt. To borrow the tapes, write 
MED 00 IB or call Autovon 294-4388. 



TEMAC PROGRAM 

The FY79 TEMAC program for Medical Corps offi- 
cers which was organized by COMNAVAIRLANT was 
extremely successful. Of the 90+ TEMAC billets which 
were authorized this fiscal year, all positions were 
filled. Next fiscal year the Medical Corps TEMAC pro- 
gram will be under administrative control of the Bureau 
of Medicine and Surgery. Individual medical officers 
who participated in the program this year are more than 
welcome to participate during FY80. Those officers 
interested in the FY80 program may contact the office 
of the Special Assistant for Naval Reserve, BUMED 
(MED 02D). Facility/activity locations and desired 
dates will be promulgated sometime in late August or 
early September. We expect to give at least six months 
lead time so that medical officers can prearrange leaves 
of absence from their practices. 



29 



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